State of Care 2019/20

Published: 16 October 2020 Page last updated: 21 October 2021


State of Care is our annual assessment of health care and social care in England.

The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.


Ian Trenholm, Chief Executive, and Peter Wyman, Chair, introduce this year's report.

Ian Trenholm and Peter Wyman


This year's main findings.

Part 1: Quality of care before the pandemic

In our State of Care report in October 2019, we said that more and better community services were needed to improve people’s experiences of care. We pointed to the need for better integrated services to prevent people ending up in crisis situations.

We showed that some places had better care than others and there were parts of the country where people might find it harder to access good care. We said that the challenge for government, Parliament, commissioners, national organisations and providers was to change the way services work together so that the right services are being commissioned to deliver what people need in their local area.

This emphasis on community and working together is not a new theme. In 2017 we reported that more local collaboration and joined-up care was needed, especially with the complexity of demand, such as diabetes, obesity, cancer and long-term conditions, increasing in a health and social care system at full stretch. We said that services had to think beyond their traditional boundaries and reflect the experience of the people they support.

In 2018 we reported how ineffective coordination of services was leading to fragmented care. Funding, commissioning, regulation and performance management all conspired to encourage a focus on the performance of individual organisations, rather than ensuring people got joined-up care based on their individual needs.

Communities matter. For several years, we have been stressing the huge importance of local health and care systems that work closely together, of collaboration among providers and local organisations to put people at the centre of their care.

The importance of this is much more apparent in the light of the coronavirus pandemic that reached this country in the last two months of 2019/20.

This report looks at the quality of care in our health and care system over the past year, including the period before COVID-19 burst into the national consciousness and began to affect everyone’s lives so fundamentally.

Part 2: The impact of the coronavirus pandemic

Part 3: Collaboration between providers

The speed and scale of the response required by the COVID-19 pandemic early in 2020 has highlighted the benefits to services, and the people who use them, of creativity and innovation through collaborative working.

In July and August 2020, we rapidly mobilised teams to carry out provider collaboration reviews in 11 different English localities, to find out how providers had worked together in the face of the pandemic. The reviews have brought into focus themes and learning that can be used to inform planning for this autumn and winter with the resurgence of COVID-19.

The reviews focused on care for people aged over 65 – the age group most impacted by COVID-19. The 11 integrated care system (ICS) or sustainability and transformation partnership (STP) areas were:

  • Bedfordshire, Luton and Milton Keynes ICS
  • Devon STP
  • Frimley Health and Care ICS
  • Lancashire and South Cumbria ICS
  • Lincolnshire STP
  • Norfolk and Waveney STP
  • North East and North Cumbria ICS
  • North West London STP
  • One Gloucestershire ICS
  • Sussex Health and Care Partnership ICS
  • The Black Country and West Birmingham STP.

We had four areas of focus for our reviews and some key questions about the response to COVID-19:

  • People at the centre: How did providers collaborate to ensure that people moving through health and care services were seen safely in the right place, at the right time, by the right person?
  • System leadership: Was there a shared plan, values and system-wide governance and leadership during the first months of the pandemic in England?
  • Workforce capacity and capability: Was there a strategy for ensuring sufficient health and care skills across the health and care interface?
  • Digital solutions and technology: What impact have digital solutions and technology had on providers and services?

To get a comprehensive picture, we spoke to a wide variety of organisations locally, including primary care networks, local medical committees, adult social care providers, social services teams, NHS trusts and independent hospitals, urgent care providers, NHS 111, community care providers, integrated care teams, urgent dental services and local Healthwatch.

The individual reviews helped to identify where provider collaboration worked well to the benefit of local people. The reviews have drawn out examples of creativity, innovation and rapid new ways of working, as well as identifying the challenges for provider partnerships and those accessing care. Sharing that learning will help drive system, regional and national learning and improvement.

Taken together, the reviews have brought into focus the themes and learning that can be used to inform planning for the coming winter and any subsequent spikes of COVID-19. But more than that, they are intended to help providers and leaders of local health and care systems plan and work more effectively together as a matter of course.

The reviews bolster recommendations we made in our 2018 report Beyond Barriers, when we called for a reform of planning and commissioning of services, particularly to support older people in their own homes. We said that a new approach was needed for system performance management and joint workforce planning, as well as better oversight of local system performance.

Our ambition is to look at provider collaboration in all ICS and STP areas in England by the end of 2020/21. Our reviews will consider the impact of collaboration across different pathways and population groups. This will include looking at how providers are re-establishing services and pathways in local areas, alongside continued responses to the impact of COVID-19. The next review will focus on how providers are working together to deliver urgent and emergency care services.

Part 4: Looking forward, the challenges and opportunities ahead

All areas of the health and care system have met the challenges of the pandemic head on, with staff going to great lengths to respond to this unprecedented health emergency. To manage the demand and keep people safe, we have seen services rapidly adapting the way they work.

But alongside the recognition that COVID-19 has fundamentally changed so much, it is important to recognise what has not changed. The problems that existed before COVID have not gone away. People are still more likely to receive poorer care from some types of service, and from some providers, for the same reasons that they would have been more likely to receive poorer care before. We will maintain scrutiny on these services and providers, supporting improvement and taking action to protect people where necessary.

Throughout the pandemic it has been important to have a learning culture and proactively respond to emerging best practice. Looking forward, we need to harness that learning and focus on what needs to be done to keep people safe, and at the same time continue to make sure people have access to high-quality care that meets their individual needs.

The commitment and resourcefulness shown by health and care staff during the pandemic has been recognised by the public in a groundswell of appreciation. Our research has shown that people are more likely to engage with their local services: since the start of the pandemic, more than two-thirds of people said they would be more likely to act to improve health and social care services, and 57% said that they would be more willing to support services by actively providing feedback on their care.

We have joined forces with Healthwatch England to launch a joint new campaign Because We All Care to help shape health and social care. The campaign aims to support and encourage more people in England to give feedback on health or social care services that they or a loved one have experienced.

It is important that the learning and innovation that has been seen during the pandemic, both in individual services and in local systems, are used to develop health and social care for the future. This applies to both the short term, in planning for the coming winter, as well as longer-term strategic planning.

State of Care

This is the 2019/20 edition of State of Care.

Go to the latest State of Care.


State of Care 2019/20



Quality of care before the pandemic

The impact of the coronavirus pandemic

Collaboration between providers

Looking forward, the challenges and opportunities ahead

Other information

Press release: Covid is magnifying inequalities and “risks turning fault lines into chasms” – focus now must be on shaping a health and care system that delivers for everyone

State of Care 2019/20: Evidence used in this report

State of Care 2019/20: Ratings data

State of Care 2019/20: Appendix - ratings charts

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You can download State of Care if you want to print it.

State of Care 2019/20

State of Care 2019/20: Easy read

Previous State of Care reports

Read previous reports about the state of health and adult social care in England on The National Archives website.